Wiki Auditing E/M coding using time


Belleville, MI
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I have a case where a doctor has been over coding his E/M visits and I have been downcoding them to the proper code. Now he has submitted a new E/M and this time he put at the end "Time spent with patient - 45 minutes."

He can say 'well I spent the entire time of 45 minutes with the patient'.

I would say 'was that time spent counseling and/or coordination of care? How do I know you didn't sit for 45 minutes and talk about the weather'?

Personally I don't think "Time spent with patient - 45 minutes." qualifies, but wanted to get some input.

Tina M Boback CPC
I am having this same issue. Sometimes I can see the counseling in the note. But the Ros and HPI leaves a lot to be desired.
Please remember that the code description says, "Physicians typically spend __ minutes face-to-face with the patient and/or family." The three KEY components are always history, exam, and medical decision making (not "typical" time spent), so it is expected that the "typical" time spent would still document the appropriate history, exam, and medical decision making. So, documenting time for the sole purpose of billing the EM is not acceptable, if the supporting detail does not correlate in some way with the three key components for the EM billed, as well as counseling, coordination of care, and nature of the presenting problem. Tried to keep this short. Hope it makes sense. :)
@ hewitt

I'm not sure I agree.

I've had patients see doctors who have closed head injures and their documentation may only meet a 99213, however he states "spent more that 50% of 43 minute visit with the patient counseling and coordination of care". In these cases I have honored the time spent as the doctor billed with a 99215.

According to the documentation for this doctor he meets a 99213, however he states "Time spent with patient - 45 minutes."
I agree with you. There is always an exception, and from your statement above, it appears those cases were exceptions. The exception was counseling, and/or coordination of care, and/or nature of the presenting problem. The combination of history, exam, medical decision plus counseling supports coding as you did.
Just an addition: Per CPT EM guidelines TIME will be considered the key or controlling factor to qualify for a particular level of E/M services and trumps the other usual required 3 components. The doctor must state that he personally spent OVER half of the time in counseling and/or coordination of care and details and this must be established firmly in the Medical record. If a physician just states as the original posted submitted, "Time spent with patient = 45 minutes", and does not elaborate as to the how and why of what was discussed, documentation would not support a time based visit. This is my understanding o the matter and probably why CPT devotes a specific paragraph to this type of coding.
I also have a physician who likes to bill using time. My understanding is that we can bill with time as long as we state more than 50% of time was spent counseling/coordinating care for the patient, the details of the counseling/coordination of care and the length of the visit.